Radiology Coding Alert

Here's how to protect your practice from the OIG crackdown

If you think of modifier -59 as an easy way to collect when you bill edited code pairs together, you may gain extra reimbursement for your claims, but you could be asking for trouble. Avoid running afoul of CMS regulators by making sure the physician's documentation makes clear the distinct and separate nature of the procedure to which you are attaching modifier -59.
 
Although several modifiers allow you to override National Correct Coding Initiative (NCCI) edits, radiology coders most often choose modifier -59 (Distinct procedural service) to separate code pairs. But in its recently released 2005 Work Plan, the Office of Inspector General at the Department of Health and Human Services  stated that it intends to scrutinize claims that include modifiers used to bypass NCCI Edits . Therefore, it's more important than ever before to ensure that you're using modifier -59 as a last resort. Follow our experts' advice to determine when you should - and should not - append modifier -59 to your claims.

If Other Modifiers Will Do the Job, Avoid -59

You should never use modifier -59 if another modifier (or no modifier at all) will tell the story more accurately. CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant .
 
In other words, -59 "is the modifier of last resort," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.
 
Coding example: The radiologist performs a diagnostic angiography prior to a therapeutic service, and he uses the results to decide on the therapy. Under these circumstances, you may code for angiography supervision and interpretation (S&I) separately by appending modifier -59. Thanks to NCCI version 10.3 - which says you can't report diagnostic codes 75650-75756 with therapeutics codes 75960, 75961 and 75970 - if you want to receive reimbursement for a diagnostic-turned-therapeutic angiography for the same patient on the same day, you've got to append modifier -59.
 
What NOT to do: Don't report diagnostic angiography along with therapeutic services if the diagnostic angiography isn't necessary because the diagnostic information is known from another test, or the diagnostic portion of the study was previously performed at another patient encounter.
 
Lesson: This example reveals how important it is to know why NCCI chose to create an edit. In this case, NCCI used the edit to correct the improper coding habit of reporting a non-diagnostic angiography as diagnostic. Other reasons for edits include a belief that you could never perform the two procedures together or are unlikely to. Knowing the reason behind the edit will help you decide whether it is OK for you to override it.

Make Sure -51 Isn't More Appropriate

"We use modifier -59 if - and only if - we perform two procedures that are typically bundled in the NCCI edits," says Elisabeth P. Fulton, CPC, coding and auditing department supervisor at Orthopedic Specialists of the Carolinas in Winston-Salem, N.C. "If the two codes appear to the insurance company that they are bundled, but should be paid because they are separately identifiable procedures, we would append the -59 modifier to the second code to correctly bypass the edit."
 
If NCCI doesn't bundle, don't use -59: "If the two procedures are not bundled, the -51 modifier (Multiple procedures) is more appropriate," Fulton says.

How often you use modifier -51 will depend on your individual payer guidelines.
 
And remember, Medicare doesn't want you to append modifier -51 to any code - they'll do that for you.

Payers Are Watching

Some insurers have grown so suspicious of modifier   -59 misuse that several payers, such as the North Dakota Medicaid program, handle modifier -59 claims by hand. If the computer detects modifier -59 on a claim, someone will manually process the claim before Medicaid will reimburse the practice.
 
Caution: The 10.3 NCCI edits (October 2004) significantly redefined and clarified modifier -59 use for Medicare claims. Under the new understanding of -59, use is generally limited to circumstances involving separate encounters, anatomic sites, or specimens, although you may override most edits for paired organs or structures if the two procedures of the code-pair edit are performed on the contralateral organs or structures.
 
For the redefinition, see the CMS Web site www.cms.hhs.gov/physicians/cciedits/nccmanual.asp.
 
Note: See "Let This Tool Do the Modifier Work for You" on page 13 to help you determine when you should select modifier -59 over other modifiers.

And to view the OIG's 2005 Work Plan, visit http://oig.hhs.gov/publications/docs/workplan/2005/2005%20Work%20Plan.pdf.